Promoting Behavior Change to Increase Engagement in Advance Care Planning

描述（由申请人提供）：预先护理计划（ACP）的概念正在发展。ACP最初的概念是这样一个过程，病人可以事先指定他们想要接受的治疗，如果他们决定失去能力。传统上，它包括完成预先指示（AD）。然而，已经证明，虽然完成文件很可能是必要的，但它本身并不足以改善生命末期的结果。这导致了ACP作为一种沟通行为的更新概念，在患者和代理人之间，以及患者和医生之间，它不关注对特定治疗的偏好，而是关注更广泛的护理目标。这些更新的概念实现了许多重要的结果，包括提高临终决策的质量，减少与替代决策相关的负担，并帮助确保患者在生命结束时接受的护理符合他们的核心价值观。对ACP患者干预研究的回顾得出结论，这些研究只有适度的效果。大多数旨在提高ACP参与率的干预措施都将重点放在ADs的完成上，并假设患者已准备好参与这种干预。然而，越来越多的证据表明，个人对参与的准备程度各不相同，针对准备参与的人的干预材料对准备较早阶段的人无效。在这方面，ACP与许多其他健康行为类似，健康行为改变模型已成为成功干预措施的框架。该项目建立在证明跨理论模型（TTM）适用于ACP的一系列工作的基础上。TTM是一种健康行为改变的模式，已被用作针对各种行为的大量且数量不断增加的有效干预措施的基础。目前的建议旨在发展一种互动的、个性化的、针对ttm的干预措施，这种干预措施可以经济有效地向大部分人口提供，同时也可以针对个人进行定制。在本提案中，ACP被定义为由四个部分组成：1)澄清护理目标；2)与代孕医生就这些目标进行沟通；3)与医生就这些目标进行沟通；4)完成书面文件。具体目标如下：主要目标1：开发一种适合TTM的干预措施，旨在提高老年人参与ACP的比例；主要目标2：通过提供干预措施的试点测试程序，评估干预材料的可接受性和清晰度，确定TTM干预措施的可行性。主要目标3。根据被试反馈修改干预材料。

DESCRIPTION (provided by applicant): The concept of advance care planning (ACP) is evolving. ACP was originally conceptualized as the process by which patients could specify in advance the treatment they would want to receive if they became decisionally incapable. Traditionally, it consisted of the completion of advance directives (AD). However, it has been shown that the completion of documents, while most likely necessary, is not in and of itself sufficient to improve end-of-life outcomes. This has led to newer conceptions of ACP as an act of communication, between patients and surrogates, and between patients and physicians, that focuses not on preferences for specific treatments but rather on broader goals of care. These newer conceptions achieve a number of important outcomes, including improving the quality of end-of-life decision-making, decreasing the burden associated with surrogate decision-making, and helping to ensure that the care patients receive at the end of life is consistent with their core values. Reviews of intervention studies to engage patients in ACP conclude that they have had only modest effects. The majority of interventions designed to increase rates of ACP participation have focused on the completion of ADs and also assume that patients are prepared for this participation. There is growing evidence, however, that individuals have variable readiness to participate, and that intervention materials aimed at persons who are ready to participate will not be effective for those at earlier stages of readiness. In this way, ACP is similar to many other health behaviors, for which models of health behavior change have served as the framework for successful interventions. This project builds upon a body of work demonstrating the applicability of the Transtheoretical Model (TTM) to ACP. The TTM is a model of health behavior change that has been used as the foundation for a large and growing number of effective interventions aimed at a wide range of behaviors. The current proposal seeks to develop an interactive, individualized, TTM-tailored intervention which can be delivered cost-effectively to large segments of a population, and at the same time, be tailored to individuals. In this proposal, ACP is defined as consisting of four components: 1) clarification of goals of care; 2) communication with surrogates physicians regarding these goals; 3) communication with physicians regarding these goals; and 4) completion of written documents. The specific aims are: Primary Aim 1: To develop a TTM-tailored intervention designed to increase the rates of older persons' participation in ACP: Primary Aim 2: To determine the feasibility of the TTM intervention by pilot-testing procedures for delivering the intervention and assessing the acceptability and clarity of intervention materials. Primary Aim 3. To revise the intervention materials based on participants' feedback. PUBLIC HEALTH RELEVANCE: Traditional approaches to interventions aimed at increasing rates of advance care planning focus are action- oriented; in other words, they provide steps that persons will take only if they are prepared or ready to participate. The proposed study, in contrast, seeks to develop an intervention providing steps for persons to take tailored to all stages of readiness. By meeting individuals' needs for behavior change, such an approach holds the promise of providing benefits to a larger portion of the population as compared to traditional intervention approaches.